Provider Demographics
NPI:1558933127
Name:NICOLOPOULOS, AMY ELIZABETH
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:ELIZABETH
Last Name:NICOLOPOULOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2243 E 12 MILE RD
Mailing Address - Street 2:
Mailing Address - City:WARREN
Mailing Address - State:MI
Mailing Address - Zip Code:48092-5644
Mailing Address - Country:US
Mailing Address - Phone:586-573-8100
Mailing Address - Fax:
Practice Address - Street 1:2243 E 12 MILE RD
Practice Address - Street 2:
Practice Address - City:WARREN
Practice Address - State:MI
Practice Address - Zip Code:48092-5644
Practice Address - Country:US
Practice Address - Phone:586-573-8100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-07-13
Last Update Date:2021-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI7501008555225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist